Modifiedpriority healthPolicy N/A

Radiation Oncology reimbursement and coding policy

Governs reimbursement, coding, documentation, and billing rules for radiation oncology services (simulation, planning, dosimetry, treatment delivery, brachytherapy, IMRT, PBT, SBRT/SRS, and related medical physics and device services) for Priority Health members.

Policy Summary

Payerpriority health

PolicyRadiation Oncology reimbursement and coding policy

Policy CodePolicy N/A

Change TypeMaterial updates to billing limits and code additions

Effective Date

Next Review DateFeb 2, 2025

Key ActionLimit billing to one unit of 77338 per IMRT plan and one unit per 8-week period; appeals require supporting documentation.

SourceLink

POLICY UPDATE CHANGES

Added code G0563 for stereotactic body radiation therapy (SBRT) delivery.

Added related denial language section listing prism denial codes E2Q and E1N for maximum frequency exceeded.

One unit of 77338 is allowed per 8-week period.

Codes 77373, G0339, and G0340 will pay only once per day of treatment regardless of the number of sessions or lesions.

Added 'Disclaimer' section.

15document length (page shown)

1/daysimulation billing limit

1/8w77338 restriction

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Billing Limits

Key coverage criteria and billing limitations

Covered when the documentation, coding, and billing rules below are met; claims lacking required documentation or that violate frequency/bundling rules may be denied or require appeal.

ALL of the following

ALL of the following
- ALL of the following
  - The service is clearly distinct from routine planning and not inherent to standard treatment plan development
  - Physician documentation demonstrating the clinical necessity for the image fusion service
  - Separate identifiable documentation and results distinguishable from other services performed
ALL of the following
- 77370 is reportable only at direct request of the radiation oncologist for high-complexity plans and is allowed one time per course of therapy
- To support 77370, documentation must include: request from treating physician, a customized written physicist report (dose calculation, blocking, other details), and inclusion of report in the patient chart
- 77370 is not reportable for routine IMRT QA
ALL of the following
- 77470 covers non-routine procedures requiring extensive time/effort and is allowed maximum quantity of one per course
- To support 77470, documentation must include: provider request, patient history/diagnosis, detailed treatment plan with advanced physics/imaging/dose calculations, procedure notes, and post-procedure assessment/follow-up as applicable
- 77470 is not appropriate for routine IMRT, routine 3-D planning, or solely because of concurrent chemotherapy unless documentation supports extensive management
ALL of the following
- In alignment with CMS, codes 77373, G0339, and G0340 will pay only once per day of treatment regardless of number of sessions or lesions
ALL of the following
- Only one beam-modifying device is billable per port/field; mirrored pairs bill as one professional and one technical device
- Only 1 unit of CPT 77338 is billable per IMRT plan and only one unit of 77338 is allowed per 8-week period; quantities in excess require appeal with supporting documentation
ALL of the following
- A typical radiation course requires 1–3 simulations and no more than one simulation code may be reported on any given day
- Verification simulations (77280) for IMRT are not billable with IMRT courses of therapy
ALL of the following
- 77300 is inclusive of isodose/port plans and only one calculation is billable per port/beam angle for 3D and IMRT; special dosimetry (77331) is billable only when prescribed and requires detailed documentation
ALL of the following
- 77336 may be reported after every 5 radiation treatments and for short courses may be billed quantity 1; retrospective record review by a physicist is not billable
ALL of the following
- Unlisted procedure code 77399 should be used only when no other code adequately describes the service and may require submission of rationale/documentation for review

Stereotactic therapy coverage and billing criteria

Stereotactic therapies are covered only when medical necessity, documentation, and the billing constraints below are met.

ALL of the following

ALL of the following
- Maximum stereotactic deliveries per course is 5 fractions; requests >5 will not be authorized as stereotactic management
- CPT 77435 (SBRT management) will pay only once per course; one 77435 may be approved when one fraction is authorized for non-cranial sites OR when 2–5 stereotactic delivery fractions are authorized for any site
- SRS is typically a single session; if >1 session is required, SBRT codes must be used
ALL of the following

Coding Tables and Key Billing Rules

Clinical treatment planningCPTCovered

77261	Therapeutic radiology treatment planning; simple
77262	Therapeutic radiology treatment planning; intermediate
77263	Therapeutic radiology treatment planning; complex

SimulationCPTCovered

77280	Therapeutic radiology simulation-aided field setting; simple
77285	Therapeutic radiology simulation-aided field setting; intermediate
77290	Therapeutic radiology simulation-aided field setting; complex
77293	Respiratory motion management simulation
G0562	Simulation including acquisition of PET/CT for radiopharmaceutical-directed RT planning

Dosimetry and isodose plansCPTCovered

77300	Basic radiation dosimetry calculation
77331	Special dosimetry (eg, TLD, microdosimetry)
77306	Teletherapy isodose plan; simple
77307	Teletherapy isodose plan; complex
77321	Special teletherapy port plan

Treatment devicesCPTCovered

77333	Treatment devices, design and construction; simple/intermediate
77334	Treatment devices, design and construction; complex
77338	MLC device(s) for IMRT, design and construction per IMRT plan

Medical physics consultationsCPTCovered

77336	Continuing medical physics consultation, per week of therapy
77370	Special medical radiation physics consultation

Special/associated servicesCPTCovered

77470

Special treatment procedure (e.g., total body irradiation)

Conventional radiation therapy deliveryCPTCovered

77402	Radiation treatment delivery: Level 1
77407	Radiation treatment delivery: Level 2
77412	Radiation treatment delivery: Level 3

Brachytherapy (electronic)CPTCovered

0395T

High dose rate electronic brachytherapy, per fraction, includes basic dosimetry

IMRTCPTCovered

77301

IMRT planning (referenced)

Proton beam therapy (PBT)CPTCovered

77520	Proton treatment delivery; simple
77522	Proton treatment delivery; simple, with compensation
77523	Proton treatment delivery; intermediate
77525	Proton treatment delivery; complex

SBRT / SRS codes and rulesmixedCovered

77371	SRS complete course, cranial, Cobalt-60, single session
77372	SRS complete course, cranial, linear accelerator based
77373	SBRT, treatment delivery, per fraction (entire course not to exceed 5 fractions)
G0339	Image-guided robotic linac-based SRS, complete course one session or first session
G0340	Image-guided robotic linac-based SRS, fractionated delivery per session (2nd-5th)
G0563	SBRT with real-time PET-based delivery adjustments

SBRT/SRS billing rulesneutralCovered

RULE-1	Codes 77373, G0339, and G0340 will pay only once per day of treatment regardless of number of sessions or lesions (CMS alignment).
RULE-2	Maximum SBRT course fractions: 5; CPT 77373/G0563 course not to exceed 5 fractions.
RULE-3	CPT 77435 pays once per course; 77417 billable 1 unit per 5 fractions (see consolidated list).

Unlisted codesCPTCovered

77399

Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services

Radiation therapy CPT/HCPCS used in policymixed

77371	SRS, complete course cranial lesion(s), 1 session; multi-source Cobalt 60 based
77372	SRS, complete course cranial lesion(s), 1 session; linear accelerator based
77373	SBRT delivery, per fraction to 1+ lesions, course not to exceed 5 fractions
G0339	Image-guided robotic linac-based SRS, complete course in one session or first session of fractionated treatment
G0340	Image-guided robotic linac-based SRS, fractionated delivery, per session second through fifth
G0563	SBRT delivery per fraction including image guidance and real-time PET-based delivery adjustments; course not to exceed 5 fractions
77432	Stereotactic radiation treatment management of cranial lesion(s), complete course, 1 session
77435	SBRT treatment management, per treatment course, to 1 or more lesions, course not to exceed 5 fractions
77387	Guidance for localization of target volume, includes intrafraction tracking
77417	Therapeutic radiology port images

1–10 of 11

1/2

Maximum SBRT fractions per course

Maximum SBRT fractions per course5

Authorization for stereotactic managementRequests >5 fractions will not be authorized as stereotactic

77435 payment rule77435 pays once per course when 1 fraction authorized for non-cranial sites or 2–5 fractions for any site

CPT 77417 billing frequency

Provider Billing Guidance, Documentation, and Denial Risk

Billing Rule

77338 billing limitation

Only one unit of CPT code 77338 is billable per IMRT plan, regardless of the number of ports constructed. Additionally, Priority Health allows one unit of 77338 per 8-week period; billing for more than one unit within that period may be denied and will require an appeal with supporting documentation.

Only 1 unit of 77338 is billable per IMRT plan
One unit of 77338 allowed per 8-week period; excess requires appeal

Billing Rule

Simulation billing guidance

A typical radiation therapy course requires between one and three simulations, and no more than one simulation may be reported on any given day. Verification simulations (77280) for IMRT are not billable with IMRT courses. Use a single appropriate simulation code (77280, 77285, or 77290) for initial set-up of superficial treatment fields; do not bill a simulation for daily placement of superficial treatment fields.

Definitions

Radiation therapy

DefinitionUse of high-energy radiation (X-rays, gamma rays, charged particles) delivered external-beam or internal (brachytherapy) to shrink tumors and kill cancer cells.

Delivery methodsExternal-beam radiation therapy (machine outside the body) or internal radiation therapy (brachytherapy) where radioactive material is placed near cancer cells.

Course componentsMay include clinical treatment planning, simulation, dosimetry, treatment devices, medical radiation physics, and treatment management.

Brachytherapy

DefinitionRadiation therapy using natural or manufactured radioactive isotopes or radionuclides temporarily or permanently implanted in or adjacent to the tumor; includes superficial, interstitial, intracavitary, or intraluminal formats.

Mechanism